just wondering can someone reassure me.yesterday at work i was giving a patient his anti clotting (tinzaparin) injection. he asked to self administer it as he normally does it himself at home.so i handed him the container and he took it out and inserted the needle into his upper arm. then he said i think its empty-so he removed it and yes it was empty. now initially i thought maybe its faulty batch and said to the patient that it must be faulty. when i left the room i mentioned it to my colleague and she said she'd never heard of it before. i then went to the box i took it from and found another the same (empty) but i cant say that both werent already used and someone put it back in box the drug press by accident thinking they werent opened. i thought i'd taken them from a brand new box though but couldntn be 100%. i feel so bad. i should have look at the entire container but i just checked the dosage/expiry and handed it over. i then reported it to the manager and the patient had bloods taken. we also filled in an incident report. i just feel i was too slow in identifying that it may have already been used- i genuonly thought it was a dud. anyway he was tested for hep c, hep b and hiv and i rang my facility earlier and they said the bloods came back clear. he's from a medical background himself. I totally accept that this was 100% my fault and whilst i know the bloods came back clear-it still happened and i am so anxious. also i thought the HIV testing took longer.
Checking for particles, amount of medication and discoloration is what I teach to do with prefilled syringes. Also, if it was empty that means someone else recapped it or it was a company flaw. Either way it can be avoided by looking at the contents in the prefilled syringes to check for issues.
I am familiar with Lovenox and it's prefilled syringes have a wrapper that must be broken in order to use it; I don't know if pharmacy does it or if they come that way. The only prefilled syringes I've seen that don't have a wrapper or seal that need to be taken off are the narcs but they come in a box neatly packaged. Even then I teach that the contents must be observed before administration.
My concern is with the self administration. I have let diabetics give their own shots after documenting teaching, care planning etc... but as far as any other meds policy at my facility states no. Is this a common practice at your workplace? Self-administration of these types of meds are reserved for if they're going home with it. Is the patient soon to be realeased? If so that could help you.
Also it was your responsibility to check the medicaiton so I wouldn't be blaming the facility because there wasn't a sharps in the room. I mean did you observe for a sharps in the room before administration and then in that event would you have stopped? Own your mistake; don't make excuses you will fair better from it. I know it seems like the end of the world but it's really the begginnig; own it, fight and then carry on.
theres never any needles lying open around the ward. but this particular type of syringe comes in little plastic pen type case and we always put it back into the case and then put it in the sharps bin.but its a little big for the small sharps bin.theres not sharp bins in the patients rooms. i'm not looking for someone to say i wasnt at fault-i 100% was at fault. i did not check the syringe was full before handing it to the patient. and i just cant believe i've made such a mistake.i havent eaten all day and keep getting upset. the patient is gone home as of today but will be followed up by the medical team and management.just dreading when they get their hands on me.
theres never any needles lying open around the ward. but this particular type of syringe comes in little plastic pen type case and we always put it back into the case and then put it in the sharps bin.but its a little big for the small sharps bin.theres not sharp bins in the patients rooms. i'm not looking for someone to say i wasnt at fault-i 100% was at fault. i did not check the syringe was full before handing it to the patient. and i just cant believe i've made such a mistake.i havent eaten all day and keep getting upset. the patient is gone home as of today but will be followed up by the medical team and management.just dreading when they get their hands on me.
At the hospital I work at, we are encouraged to report errors so that we can change the processes that caused the error to occur in the first place. So great job on your part for taking responsibility and accountability for this incident so that patient safety remains the priority. As for you, I am sure that you have learned a great deal from this, and rest assured you will be very diligent in the future. I would find it very difficult to believe that no nurse has or will not make some type of med error in their career, even if it was just a "near miss". Understandably, you are really coming down hard on yourself but you will get through this and learn from it. I really hope your facility does proper investigation into how those empty syringes ended up in the dispension box.. that will be key in changing the process to prevent future errors.
I hope everything works out well for you, don't doubt your abilities, we are human!!
Taking aside whomever might be at fault, the system in place is faulty. Even though no harm resulted this is exactly the kind of thing a root cause analysis is designed to find. If your boss isn't changing the system you should bring it to risk management. Kudos for your follow through...
its an acute medical unit. i was giving two patients their anti-clotting and had 2 in the tray. went to this man first so i know i didnt use it before or anything. the actual syringe goes back into the container and thats what we normally do and then dispose of it in the larger sharps bin. but sometimes people have a few to administer and will dispose all at once and unless they put them back into the drug trolley. i'm just dreading the consequences of this even though my main priority was the patient.feel sick and cant sleep.
I just feel like when watching whoever does that, I'd make a mental not of it, question that action, and not ever do that.
Doesnt everybodys room have a sharps container at their door?
I think nurses can loose their license for not properly disposing of used needles...or at least get fired. Thats a big thing at my work! I wouldnt say it was your fault at all.
I just feel like when watching whoever does that, I'd make a mental not of it, question that action, and not ever do that.
Doesnt everybodys room have a sharps container at their door?
Maybe not, I used to work in a facility that only 6 sharps containers (one for each med cart) and those 6 med carts & sharps containers covered 2 floors and about 150 patients.
Ya the lead up to the incident was a systems failure-i believe some colleague of mine accidentally put back the used tinzaparin in the meds press and i unfortunately was the one who gave it to a patient but the end result is completely my fault and its something that i will NEVER ever forget. i rang my manager yesterday and she told me that everything was fine and not to be worrying. she said look you'll never make that mistake again. i asked would i be brought up before mgt but she said the risk assessment committee might want to meet with you but i have no problem with that at all. all my colleagues have told me of various meds errors that they've made and others that have happened in our facility before but when YOU make the error then its very hard to be rational about it. slept a bit better last night and managed to eat something but i've never been so stressed in my life
tyvin, BSN, RN
1,620 Posts
Checking for particles, amount of medication and discoloration is what I teach to do with prefilled syringes. Also, if it was empty that means someone else recapped it or it was a company flaw. Either way it can be avoided by looking at the contents in the prefilled syringes to check for issues.
I am familiar with Lovenox and it's prefilled syringes have a wrapper that must be broken in order to use it; I don't know if pharmacy does it or if they come that way. The only prefilled syringes I've seen that don't have a wrapper or seal that need to be taken off are the narcs but they come in a box neatly packaged. Even then I teach that the contents must be observed before administration.
My concern is with the self administration. I have let diabetics give their own shots after documenting teaching, care planning etc... but as far as any other meds policy at my facility states no. Is this a common practice at your workplace? Self-administration of these types of meds are reserved for if they're going home with it. Is the patient soon to be realeased? If so that could help you.
Also it was your responsibility to check the medicaiton so I wouldn't be blaming the facility because there wasn't a sharps in the room. I mean did you observe for a sharps in the room before administration and then in that event would you have stopped? Own your mistake; don't make excuses you will fair better from it. I know it seems like the end of the world but it's really the begginnig; own it, fight and then carry on.